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Thursday, 17 April 2014

Keeping up with the Jetsons - Long Version

Last week, the BioCentre on
Ethics hosted a teleconference on the Use of Robotics in the Care of Older
People. I was on a panel with Dr Walter Greenleaf from Stanford University and
Dr Amanda Sharkey from the University of Sheffield.

We teamed up to discuss whether robotic assistive devices are more likely to
empower independent living or intensify isolation. We barely scratched the
surface. Dr Greenleaf opened the conversation reminding us that at the same
time as we are facing the acute problems of caring for ageing populations, we
are already living in an assisted world. He advocated for immediate action in
the form of targeted, solution oriented efforts and user-led ie older person
involvement in the design process. Unless actual users can be involved in all
elements of design, we will be unable to stay far enough ahead of the
predicted, large-scale physical and neurodegenerative inevitability's. Dr
Sharkey also acknowledged the predictable expansion of robotic options, in all
domains of care, but cautioned against the inherent risks, particularly with
respect to end of life care. Our overenthusiastic acceptance of
introducing human-like but not actually human helpers could qualify as an
infringement of personal dignity, in our older years. The subtext to our
exchange of viewpoints, as academics observing these developments, was on
ethical isolation amidst this burgeoning robotic innovation. Worthy of note,
the concept of robo-ethics is a mere 13 years old.

STATE OF PLAY

The fact is, the robo-genie is way out of the bottle and robotic
intervention is already occurring in every dimension of modern life. What's
needed is targeted attention on the actual application of robots to provide
assistance and care for older adults. Despite the robotic inventing taking
place in specialized, well-funded labs and the growing awareness that the
planet is ageing, a serious lack of consumer ready solutions remains. Robotics
for older people isn’t core to any business plans of the relevant players in
this market. This is relevant because we live in a commercially driven world.

Clearly, the business of robotic engineering and the business of caring
represent two distinct cultures that need to comfortably coexist and these
cultures are already intersecting. Since 2000, amazingly complex surgical procedures using robotic
arms and a surgeon operating from a console have allowed for enhanced dexterity
and more refined movements than were ever humanly possible . Add to this the
dual bonus of tremor reduction and faster recovery times for patients and there
is not much not to like about these robots! Next, it is well documented
that most people never do any rehab exercises after they leave the hospital or
physio appointment. There are now virtual avatars carrying out routine checks
to see that patients are actually doing their exercises and advising them on
proper technique.

These "relational agents" are also at the forefront of
medication management,
"watching" patients take the right meds, at the right time. This is
hugely beneficial, given that 50% of the people to whom 146M are dispensed in
the US daily are never taken, at a cost of some $2.9B annually. In addition,
diagnostic and pharmaceutical errors result in 700K drug emergencies every
year. This translates to sunk costs to the pharmaceutical industry of £180B. Big Pharma flag
bearer or not, this is material. Another recent study shows that AI, artificial intelligence algorithms,
outperform trained physicians in terms of diagnostic accuracy by 41.9%. In these
examples, there is proven synergy when artificial intelligence and robotic engineering
are combined with humans and we leverage all the new technological tools at our
disposal. The nagging question, then, is will these interactions alter the
users: surgeons, carers and the cared for's basic understanding of themselves
and if so, at what cost?

INAUTHENTIC RELATIONSHIPS

There is something called the Turing Test
that robots can take. It's a test for intelligence which requires that a human
being should be able to distinguish the machine from another human being by
using the replies to the questions put to both. Many studies have shown a
natural disposition of people (especially, older people and children) to accept
life-like robots readily as peers, despite the fact that they are machines.
This opens up the debate to concerns over inauthentic relationships.

Over ten years ago, research was conducted on an entertainment robot
animal. AIBO
was being used for treating severely demented people in a care home in Japan (Tamura et al., 2004). The conclusion was
that the AIBO was an effective rehabilitation tool, providing positive outcomes
to patients. In addition, AIBO was observed to avoid any potential danger or
injury to the patient and because it was not a real animal, cleanliness was
more easily maintained. AIBO was also attributed with the most positive
outcomes, when the AIBO was dressed. Apparently, the introduction of
humanoid characteristics and demonstrating their usefulness in predictable
environments, not situations requiring intuition or spontaneity, is the
implicit driver of good tech for older persons.

Similarly, a "welfare robot", in the form of a robotic seal
called Paro has also shown beneficial effects on
people with dementia. A landmark Danish study
aims to professionalise the use of Paro by certifying professional caretakers
in their use of the robotic seal. The objective is to determine the extent to
which new technology can support care home residents’ independence,
communication and needs for stimulation. So does the robotic seal give
care staff more time for social contacts with other residents, thereby enhance
the well-being of both parties or is this actually a clever distraction, further
limiting personal contact?

LONELINESS

And what about loneliness?
In the UK, it is estimated that over 50% of over 75 year olds who report living
alone, say their TV is their main company and 17% report that they only have
contact with a person, less than once a week. If you are being cared for by
social services, your carer may not even speak the same language as you do and
can only spend, on average, about 15 minutes, per day, per visit.

This makes it hardly surprising that neuroscientists have found higher
levels of epinephrine, the stress hormone, in the morning urine of
“lonely people”. Their research also showed that “loneliness” –
subjective social isolation – alters the basic process of DNA
transcription. We know that gene expression also disrupts perception,
behavior and physiology. Loneliness burrows deep and can become a trap that
reinforces isolation. On the positive side, loneliness and possibly depression
have both been observed to be relieved using AIBO or Paro and in much the same
way as a communication technology such as Skype works to create connectedness
in people without cognitive deficiencies.

The bottom line is this, when you introduce a robotic assistive device
into the mix you need user led design. Because older people respond differently
to any technology than do designers or technology saturated children, they need
to be included in any R&D effort. Worthy of mention, the prototypical designer of anything from F1
to a toilet seat is a 38 -year-old-white-male. What do you suppose they would
rather be working on?

ANWERS

Is there an answer? In the case of
people with dementia or other psychopathologies, are we deceiving them? If a
robot is capable of impressive caring behaviour, is that wrong? Are carers who
are good actors and exhibit impressive caring behaviour any different? In the
same way that the carer may die, the robot may fail. Is one disappointment
bigger than the other, in the mind of the cared for? Is there a distinction? Is
artificial empathy, imbued by human designers fundamentally wrong? For that matter, is first
person subjective experience or at best, realistic conscious like behaviour,
necessary for caring? I think not. However, human intervention in terms of
monitoring will for the foreseeable future, continue to be important.

Meanwhile, in all of the popular and stunningly poignant TED
talks by Henry Evans and Hugh Herror other equally important personal technology news, we see
enthusiastic people fully dedicated to reengaging with the human race. These
are the fortunate survivors, all living new lives and au fait with
their biomechanically engineered prosthesis and body surrogate robots. Some of
these come with $400K price tags, clearly out of reach for most, but they also
inspire great hope. These are authentic but they should not be
confused or compared with the radically different experience of ageing.

With ageing, function is lost unevenly and inequitably, not suddenly
and over the course of a lifetime. The application of robots in care of older
adults is uncharted territory. The needs of an ageing citizenry are no less
immediate or urgent but are unlikely to be perceived in the same way as the
otherwise disabled group. The extent to which robotic innovations will assist
or replace humans is yet unknown and the long term costs of such care are also
unknowable.

The ultimate goal of human-robot interaction in the care of older people
is to enable communication with real users in real-world environments. We need
to start training a new generation, combining specialists from both ends of the
age spectrum with specialist knowledge about technology and of actual ageing.
Currently, there are serious gaps in the linkages between product and the
population they are intended to serve (Hudson, 2014).

At present, the boomers are
watching their own ageing parents and worrying. We see the centenarians,
clutching their birthday greetings from the Queen and delight to see them being adequately celebrated,
obviously cared for. There is no hint of fear, no whiff of loss of control, no
suggestion of isolation, loneliness or neglect. They also illuminate that
the benefits of ageing are far from equitably distributed. This has further philosophical and spiritual
implications for the broad definition of caring and even categories of the
notion of “elder abuse”, be it inflicted by man or machine.

By definition, these issues are intricate, vital, and incalculable. This
is as true today as it was for the 1962 Jetsons and their indefatigible robot
house-maid, when Rosie the Robot got burned into our boomer memory banks. She was a reject, an outdated
model from U-Rent A Maid. The Jetson's only ran for 24 episodes but in that
brief time, it fired our imaginations. Despite the fact that Rosie was past her sell
by date, she ran the house while simultaneously dispensing wisdom, parental
advice and discipline. If having a robot
like Rosie, who understands where the older person is located in the home,
provide them with whatever help they want or need and provide companionship,
can this be so wrong?

Ageing is not a homogeneous
process, care needs are highly personal and fluctuating, while eventual decline
is undeniable. This debate only serves to underscore the first world nature of
this problem. Older people without cognitive decline have high demands for a
high quality of life. They need help with basic functions including cleaning,
washing and shopping that robots of the future will be able to perform.
Integrating technology with existing health and social care services makes
intuitive sense but it represents such an ambitious undertaking it is barely
conceivable. Meanwhile, sophisticated assistive care is, at present, available
to the few: the deep pocketed and participants in optimum conditions, in
controlled settings. Until sufficient interest, improved access and
affordability gaps are closed, solutions loom just out of reach (Hudson, 2014).But
this also represents a yawning ethical issue and it's racing to the fore. As
such, it is rightly under exploration. Get a move on Rosie.